HNB1205 Effects Of Medication Error Assessment 1 Answer

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Question :


Medication Safety: Identify and discuss the main causes and effects of medication errors on the lives of patients and health care providers in the health care industry. In reference to the Medication Safety Standard identify and discuss recommended strategies to minimise medication errors. 

Referring  to Peer-Reviewed Journals from the database  

• Identify and discuss the main Causes of Medication errors. 

• Discuss the Effects of Medication Errors on the lives of patients and healthcare providers.

Medication Safety Standard:  

The Australian Commission on Safety and Quality in Health Care works to improve the safety and quality of medication use in Australia. They lead and coordinate national initiatives to reduce medication errors and harm from medicines. (Australian Commission on Safety and Quality in Health Care.

• Documentation of  patient information

• clinical governance and quality improvement to support medication  management  

• Continuity of medication management  

• Medication management  processes  

• Select a minimum of two Actions from each criterion to identify and discuss strategies that have been suggested by the {ACSQHC} for health care practitioners and providers to minimise medication errors.

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Answer :

Effects of Medication Error

 In Australia, medications are important health therapy. It has recognised that around 7 in 10 Australian taking medicines for their better health. The rate is high (9 in 10) among the elder people (Roughead & Semple, 2009). In the year of 2000, the Australian Health Ministers created Australian Council for Safety and Quality in Health Care to monitor the whole situation and provide patient safety and eliminate the medication error. The organisation is working for improving the safety and quality of medication use in Australia.      

Cause of medication error

Medication error is a common phenomenon in worldwide. It has been isolated that various factors can increase the risk of medication error which includes poor coordination process, long hospitalisation, multi-morbidity, and increase cost of medicines.  Therefore, the cause of medication errors can be categorised as:

Medication errors by healthcare professionals

The common cause f medication error in acute care is a lapse error. In some cases doctors are rewriting the drugs and it slips by the healthcare professionals during the administration of the drugs. In Australia, the prescribing error observed is 2-5% whereas, the administration error occurred is 5-18% (Keers, Williams, Cooke & Ashcroft, 2013). The other common causes are failure to read the instruction or misreading the instruction of medication charts, inadequate knowledge and experience of the staffs, poor communication with patient, and workload.    

Medication error associated with patients

In some cases it has been observed that poor communication with the healthcare professionals, lack of co-ordination between the caregivers and users, and misinterpretation can increase the risk. In case of chronic illness the patients are not aware about the side effects of their medicines. In Australia, only 4in 10 chronic illness patients had written instruction from their caregivers to manage their illness at home (Roughead & Bedford, 2009). As a result the incident of medical error increased in Australia.    

Medication error associated with environment 

It has recognised that over workload, distraction, lack of standardised protocol, and insufficient resources of the healthcare facilities can elevate the risk of medication error. In industrial level, wrong labelling and naming of the medicine can cause error (Payne, Slight, Franklin & Avery, 2017). In addition, insufficient storage facilities of client’s information and records along with communication gap between the primary and secondary healthcare facilities would enhance the chances of medication error. 

Effects of medical error on patient

Effects on patients and their family 

In severe cases medication error can cause death. Thus, it can cause temporary or permanent health issues like itching, rashes, or skin deformity. In some cases it can cause severe injuries like kidney failure, respiratory distress, and heart failure and ultimate cause death (Roughead & Semple, 2009). The family can suffer a lot of mental and financial burden due to sudden devastating situation of their love ones.  

Effects on healthcare providers

The effects on caregivers who are inadvertently administrated wrong medicine can face shame, guilt, and humiliation. The person can be termed as second victim as the effects can be life threatening in some extent. The healthcare professionals can feel embarrassment in admitting their mistakes. As per Pham (2011) and his studies indicating that only 3% of the caregivers accepted their faults in front of their patients (Bari, Khan & Rathore, 2016). Thus, it prevents reconciliation, and closure on the error. It also narrowing the process of improvement or changing the system. If the authority or the individual accept their faults then the patients or their families can pursue a personal injury lawsuit against the caregivers for negligence. It can ruined career advancement and opportunities of the accused. Furthermore, litigation can increase additional emotional and social toll on the accused.         

Criterion for prevent medical error

Clinical governance and quality improvement

Clinical governance and quality improvement can support the organisation by monitoring procuring, manufacturing, storing, and compounding of medicines along with administering and observing the medicines effects in their clients. Therefore, the criterion requires commitment, governance, and leading support of the organisation to promote safety and security and eliminate the risk of medication error (Halligan, 2001). This criterion requires safety and excellence infrastructure to sustain the medication management, improve the quality of the system and review the overall medication management process. Furthermore, the criterion demands to create partnership with the consumer and train their clinical support staffs to understand their role and responsibilities. The main strategy of action is closely related with clinical governance standard and partnering with the consumer standard.

The action plan for the criterion will be:

Implementation of medical safety management 

The organisation needs to introduce and practice new process of medication safety or modify the existing one to eliminate the risk of medication error.  In this respect local project team can help in implementation, assessment, coordination, and evaluation process. The team should be multidisciplinary for handling the various incident of medication management.  Partnership with the consumer requires better care and services with satisfaction(Australian Commission on Safety and Quality in Health Care, 2019)

Monitoring the safety system

Furthermore, monitoring and evaluation of safety, performance, and quality of the medication system is essential to identify the changes overtime and the effectiveness of the system. In addition it can help to identify the positive changes which requires for betterment. The evaluation data can help the clinician to recognise their faulty behaviour which needs improvement. It can make the whole process transparent and responsible (Australian Commission on Safety and Quality in Health Care, 2019).   

Documentation of patient information

Documentation of client’s record is essential when commencing an episode of care. It can help the clinicians to get information about the medicinal allergy or adverse drugs reaction. Thus, it can reduce the chance of medical error (Collins et al., 2013).     

Action plan for the criterion:

Best possible medication history (BPMH) 

BPMH is snapshot of client’s actual medication use which can differ from the record. Patients are involved in this process and the healthcare professionals should be systematic and formal for utilising BPMH. Additionally, BPMH can ensure the continuity of medication management and help in recognising the medication related problem.     The application of BPMH on admission can decrease the risk of medication error by 50% or more (Australian Commission on Safety and Quality in Health Care, 2019). Thus, it can be documented as a part of pre admission process in case of planned admission.   Medication management plan (MMP) is helped to document the medical reconciliation and BPMH. It can apply in paediatric and adult care settings.   

Records of Medicine allergies and adverse drug reactions (ADRs)

ADRs can be classified as known and new. The adverse effects which has been experienced by the client before their care episode is termed known. On other hand, those adverse effects are experienced by the client after the episode of care is termed as new (Australian Commission on Safety and Quality in Health Care, 2019). It can help the clinician to provide alternative medicine to avoid further deterioration of the situation. In addition, the clinicians should understand the risk of adverse drug events and should make correct decision during prescribing and administrating of the medicines. The organisation incident monitoring system should recognise and report the adverse drug events to avoid the medication error. The healthcare professionals should also inform the administration system about the suspected ADRs for providing better care and services.